A National Study of American Indian and Alaska Native Substance Abuse Treatment: Provider and Program Characteristics.

American Indians and Alaska Natives (AIANs) experience major disparities in accessing quality care for mental health and substance use disorders. There are long-standing concerns about access to and quality of care for AIANs in rural and urban areas including the influence of staff and organizational factors, and attitudes toward evidence-based treatment for addiction. We conducted the first national survey of programs serving AIAN communities and examined workforce and programmatic differences between clinics located in urban/suburban (n=50) and rural (n=142) communities. We explored the correlates of openness toward using evidence-based treatments (EBTs). Programs located in rural areas were significantly less likely to have nurses, traditional healing consultants, or ceremonial providers on staff, to consult outside evaluators, to use strategic planning to improve program quality, to offer pharmacotherapies, pipe ceremonies, and cultural activities among their services, and to participate in research or program evaluation studies. They were significantly more likely to employ elders among their traditional healers, offer AA-open group recovery services, and collect data on treatment outcomes. Greater openness toward EBTs was related to a larger clinical staff, having addiction providers, being led by directors who perceived a gap in access to EBTs, and working with key stakeholders to improve access to services. Programs that provided early intervention services (American Society of Addiction Medicine level 0.5) reported less openness. This research provides baseline workforce and program level data that can be used to better understand changes in access and quality for AIAN over time.

A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities.

BACKGROUND: The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities (SNFs) and long-term care. Residents of these facilities are at a high risk for pneumococcal disease or severe influenza-related illnesses and death. For these reasons, the Centers for Medicare and Medicaid Services use influenza and pneumococcal vaccination rates as a quality measure in the assessment of SNFs, as complications related to these infections increase morbidity and mortality rates. METHODS: Disparities have been reported amongst vaccination with increased rates in urban areas as compared to their non-urban counterparts. Statistical analyses were performed to compare influenza and pneumococcal vaccination in urban and non-urban SNFs to determine variables that may influence vaccination status. RESULTS: Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5532 were considered non-urban. We found the percent of eligible and willing residents with up-to-date influenza and pneumococcal vaccinations increased with overall five-star ratings of SNFs. Somewhat paradoxically, although urban SNFs had higher mean overall five-star ratings, they showed lower rates of influenza and pneumococcal vaccination compared to non-urban SNFs. Ordinary least squares regression analysis comparing overall ratings, type of ownership, and geographic location by region yielded statistically significant results in which the overall rating, ownership-type and certificate-type favored urban SNFs (p < 0.001). CONCLUSIONS: This is the first systematic and comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban SNFs. The findings of this study may be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities.

Rural, suburban, and urban differences in factors that impact physician adherence to clinical preventive service guidelines.

PURPOSE: Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians. METHODS: This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts. FINDINGS: Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians. CONCLUSIONS: The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

Managing attention-deficit/hyperactivity disorder in primary care: a systematic analysis of roles and challenges.

OBJECTIVE: This study was designed to investigate the perceptions of primary care providers about their roles and the challenges of managing attention-deficit/hyperactivity disorder and to evaluate differences between providers who serve families primarily from urban versus suburban settings. METHODS: The ADHD Questionnaire was developed to assess primary care provider views about the extent to which clinical activities that are involved in the management of attention-deficit/hyperactivity disorder are appropriate and feasible in primary care. Participants were asked to rate each of 24 items of the questionnaire twice: first to indicate the appropriateness of the activity given sufficient time and resources and second to indicate feasibility in their actual practice. Informants used a 4-point scale to rate each item for appropriateness and feasibility. RESULTS: An exploratory factor analysis of primary care provider ratings of the appropriateness of clinical activities for managing attention-deficit/hyperactivity disorder identified 4 factors of clinical practice: factor 1, assessing attention-deficit/hyperactivity disorder; factor 2, providing mental health care; factor 3, recommending and monitoring approved medications; and factor 4, recommending nonapproved medications. On a 4-point scale (1 = not appropriate to 4 = very appropriate), mean ratings for items on factor 1, factor 2, and factor 3 were high, indicating that the corresponding domains of practice were viewed as highly appropriate. Feasibility challenges were identified on all factors, but particularly factors 1 and 2. A significant interaction effect, indicating differences between appropriateness and feasibility as a function of setting (urban versus suburban), was identified on factor 1. The challenges of assessing attention-deficit/hyperactivity disorder were greater for urban than for suburban primary care providers. CONCLUSIONS: Primary care providers believe that it is highly appropriate for them to have a role in the management of attention-deficit/hyperactivity disorder. Feasibility issues were particularly salient related to assessing attention-deficit/hyperactivity disorder and providing mental health care. The findings highlight the need not only for additional training of primary care providers but also for practice-based resources to assist with school communication and collaboration with mental health agencies, especially in urban practices.

Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.

CONTEXT AND PURPOSE: Rural and suburban populations remain underserved in terms of psychiatric services but have not been compared directly in terms of using telepsychiatry. METHODS: Patient demographics, reasons for consultation, diagnosis, and alternatives to telepsychiatric consultation were collected for 200 consecutive, first-time telepsychiatric consultations at rural and suburban clinics. FINDINGS: Rural patients were more likely than suburban patients to be younger than 18 years, using Medicaid, and needing treatment planning (lest they be referred out of the community). Rural patient and primary care physician satisfaction was higher than that of suburban counterparts. CONCLUSION: Telepsychiatry programs may enhance access, satisfaction, and quality of rural care.

Asthma care and management before an emergency department visit in children in western Michigan: how well does care adhere to guidelines?

OBJECTIVES: Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting. METHODS: We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines. RESULTS: Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider. Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas approximately 2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit. CONCLUSIONS: Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.

[Evaluating the effectiveness of child lead poisoning prevention programs]. / Evaluation des résultats d'actions de prévention du saturnisme infantile.

PROBLEM: A multi annual screening and prevention program against lead poisoning was implemented in a suburb of the Paris area. We attempted to assess the effectiveness of this program based on data available from children screening and follow-up. METHODS: Indicators of effectiveness included the evolution of blood lead levels at screening and the frequency of secondary increases in blood lead levels. Buildings inclusion dates were used to control for the increasing selection of less exposed children. RESULTS: A total of 3,660 children were screened between 1992 and 2000. We observed a regular decrease in blood lead levels at screening, in the highest blood lead levels obtained for each child and in the proportion of children whose blood lead levels increased after screening: the proportion of children with initial blood lead levels >=15 micro g/dl fell from 17.4% in the 1992-1996 period to 4.1% in the 1997-2000 period. A multivariate analysis taking into account the first year that children were screened in a given building showed that less exposed children were included over time, but found also an additional independent decrease in blood lead levels that can be related to the effectiveness of prevention efforts. A "building by building" analysis of 30 buildings where more than 20 children were located over the whole study period confirmed that the incidence of lead poisoning decreased within most of these buildings. CONCLUSIONS: Taking into account buildings'inclusion dates makes it possible to distinguish program effectiveness from the consequences of including less exposed children The effectiveness of preventive actions is associated with several interacting factors, including the participation of families and the active involvement of local technical staff and policy makers. The finding that the decrease in blood lead levels leveled off after 1997 calls for further actions.

[How long does it take for an ambulance to arrive?]. / Hvor lang tid tar det før ambulansen kommer?

BACKGROUND: There are few Norwegian recommendations for quality and efficacy of ambulance performance. A report commissioned by the Ministry of Health and Social Affairs concluded that the ambulance service was the weakest link in the chain of survival. The report proposed standards for response intervals in emergencies: 90% of the population in cities and urban areas should be reached by an ambulance within eight minutes. In rural areas, 90% should be reached within 25 minutes. MATERIAL AND METHODS: This study describes the ambulance response interval for the 2,589 red code emergencies in the 15 municipalities in Vestfold County in 1998, a county with a population of 208,687, or 97.5 inhabitants per square kilometre, with seven ambulance stations. A retrospective analysis was made of data for the year 1998. RESULTS: The proposed standard was not reached in any municipality in the county. The city of Tønsberg had the best performance, but even here only 48.9% of the population were reached by ambulance within eight minutes. The worst performance was found in the rural municipality of Tjøme; here, only 63.3% were reached within 25 minutes. INTERPRETATION: Achieving the standards proposed will require a major restructuring of existing ambulance services.

Quality and bioavailability of ampicillin capsules dispensed in a Nigerian semi-urban community.

Five samples of ampicillin capsules with a label claim of 250 mg were purchased from different dispensing points in a small town in Nigeria. The pharmaceutical quality of the products and a sample from a batch produced by a local manufacturer was evaluated and five of the capsule samples were employed in an in vivo bioavailability study. Three of the five capsule samples from dispensing points were found to be of lower quality than the officially prescribed standards of pharmaceutical quality. The quality lapses observed were sufficient to bring about determinable differences in biological availability. The results demonstrate that ampicillin capsules of sub-standard chemical quality are being dispensed within the study sources from authorised and unauthorised sources and that this may have biological, clinical and epidemiological consequences.

Promoting breastfeeding through health education at the time of immunizations: a randomized trial from Guinea Bissau.

As an intervention against diarrhoea, promotion of breastfeeding has been suggested by the World Health Organization (WHO). In the present study from Guinea Bissau we tested the possibilities of promoting breastfeeding at a local health centre. A total of 1250 children were allocated randomly into two groups. Mothers in the intervention group were given health education according to WHO's recommendations; about exclusive breastfeeding for at least the first 4 mo, prolonged breastfeeding and family planning methods. At 4 mo of age introduction of weaning food was delayed in the intervention group (risk rate 1.18 (95% CI 1.03-1.38) and more mothers had an IUD inserted (risk rate 2.45 (1.27-4.70). The median length of breastfeeding was 23 mo in both groups. There was no difference in the number of children weaned early. Although exclusive breastfeeding was promoted by the intervention, early weaning of children in special risk groups was not avoided. An evaluation of the impact of the WHO recommendations in different settings is warranted.

Randomized controlled trial of general practitioner versus usual medical care in a suburban accident and emergency department using an informal triage system.

We determined if care provided by general practitioners (GPs) to non-emergency patients, in a suburban accident and emergency (A&E) department using an informal triage system, differs significantly from care provided by usual A&E staff. One thousand eight hundred and seventy-eight patients participated. By comparison with usual A&E staff, GPs prescribed significantly more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the first study to report that sessional GPs working in an A&E department utilize similar or more resources than usual A&E staff. It emphasizes the need for the continued audit of initiatives that have been introduced into new settings.

The effect of consumer perceptions of quality and sacrifice on hospital choice: a suburban vs. urban competitive scenario.

The primary objective of this research was to determine how a suburban hospital located near an urban center fares when local consumers are selecting a hospital. A significant portion of the 161 suburban respondents to the study's mail survey perceive the quality of care available at alternative urban hospitals to be higher than that available at their local suburban hospital on the vast majority of quality-related attributes. Most respondents, however, select their local hospital for both major and minor medical treatment. Te greater value represented by suburban hospitals, due to their relative closeness to the consumer, represents a significant competitive advantage.